Last updated: 9 February 2026
"Safe staffing, regular training with supervisions and a supportive culture, but ineffective management fails to learn from incidents and limits activities on one floor."
People were protected from abuse ... Risk assessments had been completed and staff were provided with clear guidance ... People received their medicines as prescribed. However, the service did not have robust systems to identify learning following incidents
Staff told us, “The culture is good amongst the staff and we all support each other”, “They are residents but they also become family" and “It is good here. ... management are really good so we can share any problems"
The service was safely staffed and rotas demonstrated planned staffing levels were achieved. Records showed agency staff were used infrequently to cover periods of annual leave or unexpected staff absences.
Staff completed a formal induction process when they joined the service and their training was regularly refreshed and updated. Staff comments included, “we will be having e-learning every month and every year we have fresh courses. Every month we have a supervision"
Governance systems were not effective, and managers had failed to act on audits or identify areas of improvement following incidents that occurred.
The provider employed a full-time activities coordinator who was effective in supporting people to engage in activities individually and as part of small groups. ... people in the mental health unit were supported to visit the local town regularly. However, ... on the first floor ... limited opportunities
Managers do not always spot risks or learn from accidents like window escapes and poor audits.
The service did not have robust systems to identify learning following incidents that occurred. Additional checks had not been completed following an incident where a person left the service without support via a window.
On the first floor, shifts are mostly task-focused personal care with few activities to mix it up.
On the first floor of the older persons service, care was task based and there were limited opportunities for people to take part in activities. Relatives told us puzzles and games were missing pieces.
Some infection control issues like uncovered bins and dirty towels were missed by checks.
Infection control guidance was not consistently followed, and audits had failed to identify issues in relation to lack of bin covers and storage of towels in shared bathrooms.
AI Generated
Last inspected: July 2025
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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